05040100CITY OF CUPERTINO
BUILDING DIVISION PERMIT
e
:CONTRACTORII FORMATIO i
BUILDING ADDRESS:
HILLHOUSE CONSTRUCTION
PERMITNOO50401OO
OWNER'S NAME:
PERMIT ISSUE DATE
IS:
SANITARY Q&kOL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BO EO PLUOMB MEOCH
LICENSED CONTRACTOR'S DECLARA71ON
j77��^GDYYtt111.,,,, tr1�����-
ed
1 affirm Net I am licensed under
of or Chapter 9 (commencingIt...
�Cj
Poitou
naaand Profcssior Co@,andmyIkencih
with Section 7000) ofDbutI 3olithe And
ion 70
�
in full forte end effec
TI--INTER: REMODE `�P�o�
L"An clw Lk.N
c. man
ARCHTECPS DEC RATION
acco
I understand my plans thtll he used As accords
(O O 2005
2005
LU J
Licensed Pmessional
OWNER-BUILDER DECLARATION
I hereby afOm that I em exempt from the Consomme, Licence Law for the
' 1
BU
following moon. (Section 703 1.5, Bualmr. and ons Code: Any city os county
ILL) 14%.7.
w, de m repair any
which requires pmmit Aa alalic. Imrrow,
s s @£J'
uiresconstruct,
h Permit I mmment
pilarmitsensedpaim regn the theisionsnt f Conrcmtuofileasignedshlcmcnt
prior issuance,
that nt.OeenmardrsuammtheprovisoionftheBeat. UmrmLaw 9
Sq. Ft. Floor Area
Va anon
onsCod(Chapter
finjaxe with of Division of tit" B vi Cade)ar
Profession.
exam
amlfann and ed
that k b exempt dere(rom and the bub for Nn alleged ewnptron. Any Wolation of
dust he s lf3 t Any
3 8VN1N)0*4rO 0
Occupancy Type
Section 7031.5 by any applicant for a permit objects the applicant In a civ0 penalty of
not mom than Ove hundmd dollars ($5001.
❑ I• As owner of the preperly, or my employees with wages as Noir sols compensation.
Required Inspections
ets
will do the work• and thestrumure Isnot Intended aro@red fouale(Sm. 7011. Business
code: The C.mrame es License law donot apply h an awr of
and Ptufasdme m
9 P
property who buildsm impmwatherecn,md whodoeasuch warkhimmlf or Wough his
ownemployees, provided that such improvements sac not Intended aroRerM for sale. If.
however. the building or Improvement It sold within one yen of completion. the owner.
builder will have dm burden of proving that k did not Wild or Improve for purpose of
sale.).
Q 1, as owner of the property. am "elusively contracting with licensed contractors in
construct the project (Sec. 70". Business and Professions Code:) The Contractees U.
came law doe not apply in an owner of property who Wilda or improv Nemon, red,
who contracts for such projects with A eantrmmr(s) licensed pursuant to the Commences
License Law.
❑ 1 Am exempt under Sec. , 8 k P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aMm muter penally of pedury ane Aida following declantion
Rum and will maintain. CeNBete of Cotuem to xK.I.Som forWorker's Compm.
l
sation. u provided for by Section 3700 a( the Labor Code, for the Performance of the
work for which this Permit Is issued.
❑ I have and will maintain Worker's Compensation Insurmce. As required by Section
3700 Ardor Labor Code. for the performance of the wart far which this Permit is issued.
My Warner' mpenmdon Insurance carie and Policy numberate:
Grtier. � Polity No.:Jy'rn��- —
CERTIFICATE OF ON FROM WORKERS'
'
COMPENSA71ON INSURANCE
Curb seeim aced Act be can plc ted Ethic pare it b far om hundred dollar (S 100)
lir leu.)
1 sonify that In the perfomanco or the work for which this remit is Issued. I shall not
employ Any person in any manner an as At Weomesubject to the Workers'Compensation
Laws of Califomic Data
Applicant
NGrICE TO APPLICANT: If. after making thb Cmifiam of Exemption. you should
become subject In the Workers Compensation previsions of the labor Code. you most
'
forthwith comply with such provisions or this permit shall k domed mwtkcd.
CONMUCTION LENDING AGENCY
I hereby alfmm Nat Vert is a mmuuctin t lending agency for the performance of
U. work for which this remit b issued (Sec. 309'1. Co. C.)
Lender's Name
L.mm,'. Address
I Certify that I haw rsed this application and sum that the akw Information Is
'
Correa. i ogre in comply with all city and county ordinances and state laws mixing at
Wilding construction, and hereby authorize rePrnxnu0v of this city in enter upon the
above-mentioned property for inspection purposes.
(We) agree to saw. Indemnify and keep harmless the City of Cupertino against
j liabilities, judgmcnh,coro andexpc .which my in any way acemc agemn mid City
mmregben garting.f n— .
i APP. MCA? U SrAND AND WI COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE S.
Re-roofs
Type of Roof
ten o Appian om Dam
HAZA Or, S MATERIALS DISCLOSURE
Will the applicust or future building occupant atom or handle hnardoes material
As deOmd by the Cupertino Municipal Cade. Charm, 9.12. and the Haws and Safety
Cuba. Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑tics ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ne applicant or return building occupant use equipment or device which
I harudae air contaminants u mhood by the Bay Area Air Quality Management
all new materials for inspection.
rrict7
❑Yes ❑Nu
I have read the hnardma materials requirements under Chspwrd.95 arthe Caliror.
lib H"IN Code. 23 ,x3533 am1235N.Iundemmd thulfdc building
d! n cumntl be tenma It b mY estality h notify the occupant of dm
re mor ch u tParm." ofacmummearampancy.
Signature Applicant Date
of
All roof coverings to be Class "B" or better
Aorauna ir, enl Data